Analysis Vessel Loading In the late afternoon when the operator began to load the workboat with used shingles, he was faced with the choice of making two trips with a reduced load, or taking a risk by heavily loading the vessel for one trip. It was reported to the TSB that the owner claimed to have loaded the vessel to this draught in the past. People who successfully perform risky acts on the job often change their attitudes or opinions about the personal risk involved. They tend to discount the risk and may even come to believe that the activity is no longer risky. They may also develop a sense of their own invulnerability. The more often they succeed at the dangerous act, the more likely they are to believe that, although the practice may be dangerous in a general sense, nothing bad will happen to them. This attitude can lead them to repeat the act, and repeated success further reinforces the behaviour. The more often they do it, the more they feel justified in their sense of invulnerability. The more comfortable they become with the risky behaviour, the more likely they are to reduce the margin for safety.8 On the day of the occurrence, the operator was willing to accept the risk involved in loading the excessive weight of shingles because he had heavily loaded the vessel in the past without adverse consequences. Reducing freeboard on any vessel results in lower margins of safety in rough weather. For small vessels of open construction, it is essential that adequate freeboard be maintained in relation to weather conditions. The load of shingles taken on board just prior to the occurrence reduced the effective freeboard of the vessel to 0.2m. Upon reaching unprotected water in mid lake, the vessel was travelling almost directly into the prevailing weather. Wave heights were 0.6m and the vessel began to ship water over the bow. It is possible that the operator slowed down suddenly to prevent further water coming over the bow, or to avoid debris in the water. However, the amount of shingles carried on the voyage had reduced the vessel's freeboard such that the sudden and rapid deceleration of the vessel caused the bow to immediately drop onto an oncoming wave and swamp the boat. Regulatory Overview All passengers (whether they are tourists or construction workers) travelling on commercial vessels, regardless of size, have an expectation that the vessel is safe, the operator competent, and that they will not be put at undue risk by the voyage. In Canada, the use of small commercial vessels to carry passengers engaged in the construction industry is not uncommon. Workers carried as passengers on small commercial vessels are subject to a combination of federal and provincial regulations. There are no clear provincial requirements to lessen the risk of drowning for workers being transported over water to and from construction projects. Federal regulations, while specifying what safety equipment is to be on board, do not require passengers to wear lifejackets. Further, neither Ontario nor federal regulations contain provisions to protect workers against hypothermia when travelling as passengers on small commercial vessels, should the vessel sink or capsize. Without the aid of a lifejacket or a thermal protective aid, hypothermia rapidly reduces an individual's ability to stay afloat or swim. Muscles in the arms and legs become rapidly numb, leading to paralysis. Sudden immersion in cold water may also cause hyperventilation and associated panic, further reducing a person's ability to remain afloat.9 At the location of the occurrence, the minimum distance to shore was 500m. Immersed in water of 8 C, a person without a flotation device has between 30and 60minutes, and less than a 50percent chance of swimming 50m, before becoming incapacitated to the point that they cannot stay afloat. Being employed in the roofing trade, the roofing crew's level of fitness was relatively high, which gave them the stamina required to swim to shore. However, as a result of the low water temperature - brought about by spring runoff conditions on Anstruther Lake - and the lack of thermal protective aids, the roofing crew experienced advanced hypothermia and the ability of these workers, and of the operator, to stay afloat unaided, or swim to shore, was compromised. Responsibility for assessing the condition of the vessel and the competence of operators of commercial passenger vessels falls under the jurisdiction of TC. TC provides operators with a national regulatory system that applies to the structural and operational safety of the vessel, to ensure that the vessel can be navigated safely. Due to the size of the vessel, (under 5 grt) and number of passengers carried (12orfewer) the vessel involved in this occurrence was not required to undergo annual inspections by TC, however an initial inspection prior to entering service was required. While the operator was required to have taken Marine Emergency Duties training, he was not required to hold a certificate of competency. However, as a commercial passenger vessel under 15grt carrying not more than 12passengers, the workboat was subject to the requirements of the SVMIP. It is unknown whether the operator was aware of the SVMIP or the benefits that voluntary compliance with the program could bring. At the time of the occurrence, however, TC was unaware that the vessel was operating as a small passenger vessel and neither the vessel nor its lifesaving equipment had been inspected by TC. Provincial governments have the responsibility to ensure that construction activities necessitating the use of small commercial vessels are conducted in a safe manner. In the absence of a mandatory inspection by TC, there is still a need to ensure that construction crews are afforded a minimum level of safety. The proactive measures taken by the Province of Quebec in1998 have effectively linked the requirements for vessel inspections and insurance with the province's business licensing system. In this manner, the province ensures vessels in the construction and small passenger vessel industry are vetted and a minimum level of safety established. At the time of the occurrence, at least one other commercial vessel service operating on Anstruther Lake was not listed in the TC ship inspection database. Similar commercial marine services supporting the construction industry are common across the country. Programs similar to the Quebec initiative do not exist in other provincial jurisdictions. In the absence of effective federal and provincial regulatory requirements, passengers on small commercial vessels may be put at undue risk. Findings Findings as to Causes and Contributing Factors The operator heavily loaded the vessel because he had done so previously without adverse consequences. The shingles reduced the vessel's freeboard such that, when the vessel was suddenly slowed, the bow immediately dropped onto the oncoming wave which swamped the vessel. As a result of the low water temperature - brought about by spring runoff conditions on Anstruther Lake - and the lack of thermal protective aids, the roofing crew experienced advanced hypothermia and the ability of these workers and of the operator to stay afloat unaided, or swim to shore, was compromised. Findings as to Risks Neither Ontario nor federal regulations make provisions to protect workers against hypothermia when travelling as passengers on small commercial vessels - should the vessel sink or capsize. In the absence of effective federal and provincial regulatory requirements, construction workers being carried as passengers on small commercial vessels may be put at undue risk. As a result of an inadequate safety briefing prior to departure, the roofers did not make use of all the available flotation devices, such as those stored in the plastic bin. Other Findings Transport Canada was unaware that the vessel was operating as a small passenger vessel and had not inspected either the vessel or its lifesaving equipment.